Nurses, community health workers, and home carers: gendered human resources compensating for skewed health systems

Opening up the 'black-box': what strategies do community mental health workers use to address the social dimensions of mental health?

PURPOSE

Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India.

METHODS

We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically.

RESULTS

CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD.

CONCLUSION

Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

Applying a Power and Gender Lens to Understanding Health Care Provider Experience and Behavior: A Multicountry Qualitative Study

A limited but growing body of literature shows that health care providers (HCPs) in reproductive, maternal, and newborn health face challenges that affect how they provide services. Our study investigates provider perspectives and behaviors using 4 interrelated power domains-beliefs and perceptions; practices and participation; access to assets; and structures-to explore how these constructs are differentially experienced based on one's gender, position, and function within the health system. We conducted a framework-based secondary analysis of qualitative in-depth interview data gathered with different cadres of HCPs across Kenya, Malawi, Madagascar, and Togo (n=123). We find across countries that power dynamics manifest in and are affected by all 4 domains, with some variation by HCP cadre and gender. At the service interface, HCPs' power derives from the nature and quality of their relationships with clients and the community. Providers' power within working relationships stems from unequal decision-making autonomy among HCP cadres. Limited and sometimes gendered access to remuneration, development opportunities, material resources, supervision quality, and emotional support affect HCPs' power to care for clients effectively. Power manifests variably among community and facility-based providers because of differences in prevailing hierarchical norms in routine and acute settings, community linkages, and type of collaboration required in their work. Our findings suggest that applying power-and secondarily, gender lenses-can elucidate consistencies in how providers perceive, internalize, and react to a range of relational and environmental stressors. The findings also have implications on how to improve the design of social behavior change interventions aimed at better supporting HCPs.

"We are everyone's ASHAs but who's there for us?" a qualitative exploration of perceptions of work stress and coping among rural frontline workers in Madhya Pradesh, India

OBJECTIVE

More than a million female village-level lay providers called 'Accredited Social Health Activists (ASHAs)', who deliver primary care, face high levels of stress due to work demands and low compensation, within the context of poverty and gender inequality. Evidence on ASHAs has focused on workplace challenges from a system perspective, without sufficient probing into individual-level stress. This study aims to gain perspectives into the experiences of work stress, the related health symptoms, and the responses to stress among ASHAs in India.

METHODS

Focus group discussions (FGDs) conducted with ASHAs in Sehore district, Madhya Pradesh, were audio-recorded and transcribed. Grounded theory was used to generate themes under the various domains of ASHAs' work and domestic life. We identified pathways between the conditions that trigger stressful events, experiences of these events, resulting perceptions, effects on health and wellbeing, and approaches used by ASHAs to respond to stress.

RESULTS

Six FGDs with 59 ASHAs generated the following themes: (a) Facility: Workload, undue pressures, unstructured work; ASHAs' relationships with seniors (e.g., feelings of being disrespected, blamed, or targeted), and low access to physical and administrative resources; (b) Home: Feelings of guilt for putting less time for family/child care; disrespect by the elderly for a poorly incentivised job; (c) Community: Low acceptance by the villagers; caste- and gender-bias; difficult community-level relationships (emotional labour, fear/stigma towards her services); (d) Somatic and psychological symptoms: headache, exhaustion, depressive symptoms (to cite a few); and (e) Responses to stress: Motivation (support from peers, family, a sense of identity/pride, incentives), Individual strengths (e.g., social responsibility), and spiritual recourse mechanisms.

CONCLUSIONS

This study will inform the development of a strengths-based coaching intervention to address work stress among ASHAs. The findings are relevant to building the evidence on alleviation of work stress among female frontline cadres in low-resource settings globally.

"Helping Mentally Ill, a Reward Both in this Life and After": A Qualitative Study Among Community Health Professionals in Somaliland

This study aimed to describe the experiences of community mental health workers, predominantly female, nurses and doctors providing community-based mental health services in Borama, Somaliland. A qualitative explorative study using focus group discussions was conducted. Data were collected from three focus group discussions with 22 female community health workers, two medical doctors, and two registered nurses and analyzed using content analysis with an inductive approach. Three main categories were identified from the analysis: (1) bridging the mental health gap in the community; (2) working in a constrained situation; and (3) being altruistic. Overall, the community mental health workers felt that their role was to bridge the mental health gap in the community. They described their work as a rewarding and motivated them to continue despite challenges and improving community healthcare workers' work conditions and providing resources in mental health services will contribute to strengthening mental health services in Somaliland.

When women win, we all win-Call for a gendered global NCD agenda

Gender is a social determinant of health, interacting with other factors such as income, education, and housing and affects health care access and health care outcomes. This paper reviews key literature and policies on health disparities and gender disparities within health. It examines noncommunicable disease (NCD) health outcomes through a gender lens and challenges existing prevailing measures of success for NCD outcomes that focus primarily on mortality. Chronic respiratory disease, one of the four leading contributors to NCD mortality, is highlighted as a case study to demonstrate the gender gap. Women have different risk factors and higher morbidity for chronic respiratory disease compared to men but morbidity is shadowed by a penultimate research focus on mortality, which results in less attention to the gap in women's NCD outcomes. This, in turn, affects how resources, programs, and interventions are implemented. It will likely slow progress in reducing overall NCD burden if we do not address risk factors in an equitable fashion. The article closes with recommendations to address these gender gaps in NCD outcomes. At the policy level, increasing representation and inclusion in global public health leadership, prioritizing NCDs among marginalized populations by global health societies and political organizations, aligning the gendered global NCD agenda with other well-established movements will each catalyze change for gender-based disparities in global NCDs specifically. Lastly, incorporating gender-based indicators and targets in major NCD-related goals and advancing gender-based NCD research will strengthen the evidence base for women's unique NCD risks and health outcomes.

Not knowing enough, not having enough, not feeling wanted: Challenges of community health workers providing maternal and newborn services in Africa and Asia

BACKGROUND

Community health workers (CHWs) have been identified as a critical bridge to reaching many communities with essential health services based on their social and geographical proximity to community residents. However, various challenges limit their performance, especially in low-and middle-income countries. With the view to guiding global and local stakeholders on how best to support CHWs, this study explored common challenges of different CHW cadres in various contexts.

METHODS

We conducted 36 focus group discussions and 131 key informant interviews in Bangladesh, India, Kenya, Malawi, and Nigeria. The study covered 10 CHW cadres grouped into Level 1 and Level 2 health paraprofessionals based on education and training duration, with the latter having a longer engagement. Data were analysed using thematic analysis.

RESULTS

We identified three critical challenges of CHWs. First, inadequate knowledge affected service delivery and raised questions about the quality of CHW services. CHWs' insufficient knowledge was partly explained by inadequate training opportunities and the inability to apply new knowledge due to equipment unavailability. Second, their capacity for service coverage was limited by a low level of infrastructural support, including lack of accommodation for Level 2 paraprofessional CHWs, inadequate supplies, and lack of transportation facilities to convey women in labour. Third, the social dimension relating to the acceptance of CHWs' services was not guaranteed due to local socio-cultural beliefs, CHW demographic characteristics such as sex, and time conflict between CHWs' health activities and community members' daily routines.

CONCLUSION

To optimise the performance of CHWs in LMICs, pertinent stakeholders, including from the public and third sectors, require a holistic approach that addresses health system challenges relating to training and structural support while meaningfully engaging the community to implement social interventions that enhance acceptance of CHWs and their services.

Philanthropic Foundations' Discourse and Nursing's Future

In this article, we examine external agents' effect on nursing's professional evolution and the consequences for the discipline's collective agency, social contract, and self-regulation. Situated within Foucault's theories of power, we review how the power of organizations reaches into the fabric of everyday life and explore how philanthropic foundations have influenced a diverse array of disciplines, including nursing. Through a genealogic lens, we examine nursing history and professionalization and conclude with concerns surrounding nursing's exercise of its collective agency during one of the most significant, discipline-shaping activities of modern times-Robert Wood Johnson Foundation's Future of Nursing initiatives.

The Use of Intersectional Analysis in Assessing Women's Leadership Progress in the Health Workforce in LMICs: A Review

BACKGROUND

Human resources are at the heart of health systems, playing a central role in their functionality globally. It is estimated that up to 70% of the health workforce are women, however, this pattern is not reflected in the leadership of health systems where women are under-represented.

METHODS

This systematized review explored the existing literature around women's progress towards leadership in the health sector in low- and middle-income countries (LMICs) which has used intersectional analysis.

RESULTS

While there are studies that have looked at the inequities and barriers women face in progressing towards leadership positions in health systems within LMICs, none explicitly used an intersectionality framework in their approach. These studies did nevertheless show recurring barriers to health systems leadership created at the intersection of gender and social identities such as professional cadre, race/ethnicity, financial status, and culture. These barriers limit women's access to resources that improve career development, including mentorship and sponsorship opportunities, reduce value, recognition and respect at work for women, and increase the likelihood of women to take on dual burdens of professional work and childcare and domestic work, and, create biased views about effectiveness of men and women's leadership styles. An intersectional lens helps to better understand how gender intersects with other social identities which results in upholding these persisting barriers to career progression and leadership.

CONCLUSION

As efforts to reduce gender inequity in health systems are gaining momentum, it is important to look beyond gender and take into account other intersecting social identities that create unique positionalities of privilege and/or disadvantage. This approach should be adopted across a diverse range of health systems programs and policies in an effort to strengthen gender equity in health and specifically human resources for health (HRH), and improve health system governance, functioning and outcomes.

"We are nurses - what can we say?": power asymmetries and Auxiliary Nurse Midwives in an Indian state

In India, nurses and midwives are key to the provision of public sexual and reproductive health services. Research on impediments to their performance has primarily focused on their individual capability and systemic resource constraints. Despite emerging evidence on gender-based discrimination and low professional acceptance faced by these cadres, little has been done to link these constraints to power asymmetries within the health system. We analysed data from an ethnography conducted in two primary healthcare facilities in an eastern state in India, using Veneklasen and Miller's expressions of power framework, to explore how power and gender asymmetries constrain performance and quality of care provided by Auxiliary Nurse Midwives (ANMs). We find that ANMs' low position within the official hierarchy allows managers and doctors to exercise "power over" them, severely curtailing their expression of all other forms of power. Disempowerment of ANMs occurs at multiple levels in interlinked and interdependent ways. Our findings contribute to the empirical evidence, advancing the understanding of gender as a structurally embedded dimension of power. We illustrate how the weak positioning of ANMs reflects their lack of representation in policymaking positions, a virtual absence of gender-sensitive policies, and ultimately organisational power structures embedded in patriarchy. By deepening the understanding of empowerment, the paper suggests implementable pathways to empower ANMs for improved performance. This requires addressing entrenched gender inequities through structural and organisational changes that realign power relations, facilitate more collaborative ways of exercising power, and create the antecedents to individual empowerment.

What constitutes 'good' home care for people with dementia? An investigation of the views of home care service recipients and providers

BACKGROUND

Our objective was to explore what people receiving and providing care consider to be 'good' in-home care for people living with dementia.

METHODS

We conducted 36 in-depth interviews and two focus groups with key stakeholders in Australia in the first quarter of 2018. Participants included those receiving care (4 people living with dementia, 15 family carers) or providing care (9 case managers, 5 service managers, 10 home care workers). Qualitative thematic analysis was guided by Braun and Clarke's six-step approach.

RESULTS

Consensus was reached across all groups on five themes considered as important for good in-home dementia care: 1) Home care workers' understanding of dementia and its impact; 2) Home care workers' demonstrating person-centred care and empathy in their care relationship with their client; 3) Good relationships and communication between care worker, person with dementia and family carers; 4) Home care workers' knowing positive practical strategies for changed behaviours; 5) Effective workplace policies and workforce culture. The results contributed to the co-design of a dementia specific training program for home care workers.

CONCLUSIONS

It is crucial to consider the views and opinions of each stakeholder group involved in providing/receiving dementia care from home care workers, to inform workforce training, education program design and service design. Results can be used to inform and empower home care providers, policy, and related decision makers to guide the delivery of improved home care services.

TRIAL REGISTRATION

ACTRN 12619000251123 .

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats.

Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups.

Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats.

Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Balancing roles and blurring boundaries: Community health workers' experiences of navigating the crossroads between personal and professional life in rural South Africa

As demand for health services grows, task-shifting to lay health workers has become an attractive solution to address shortages in human resources. Community health workers (CHWs), particularly in low-resource settings, play critical roles in promoting equitable healthcare among underserved populations. However, CHWs often shoulder additional burdens as members of the same communities in which they work. We examined the experiences of a group of CHWs called Mentor Mothers (MMs) working in a maternal and child health programme, navigating the crossroads between personal and professional life in the rural Eastern Cape, South Africa. Semi-structured qualitative interviews (n = 10) were conducted by an experienced isiXhosa research assistant, asking MMs questions about their experiences working in their own communities, and documenting benefits and challenges. Interviews were transcribed and translated into English and thematically coded. Emergent themes include balancing roles (positive, affirming aspects of the role) and blurring boundaries (challenges navigating between professional and personal obligations). While many MMs described empowering clients to seek care and drawing strength from being seen as a respected health worker, others spoke about difficulties in adequately addressing clients' needs, and additional burdens they adopted in their personal lives related to the role. We discuss the implications of these findings, on an immediate level (equipping CHWs with self-care and boundary-setting skills), and an intermediate level (introducing opportunities for structured debriefings and emphasising supportive supervision). We also argue that, at a conceptual level, CHW programmes should provide avenues for professionalisation and invest more up-front in their workforce selection, training and support.

Community health workers: challenges and vulnerabilities of Accredited Social Health Activists working in conflict-affected settings in the state of Assam, India

INTRODUCTION

It is well acknowledged that India's community health workers known as Accredited Social Health Activists (ASHA) are the bedrock of its health system. Many ASHAs are currently working in fragile and conflict-affected settings. No efforts have yet been made to understand the challenges and vulnerabilities of these female workers. This paper seeks to address this gap by bringing attention to the situation of ASHAs working in the fragile and conflict settings and how conflict impacts them and their work.

METHODS

Qualitative fieldwork was undertaken in four conflict-affected villages in two conflict-affected districts -Kokrajhar and Karbi Anglong of Assam state situated in the North-East region of India. Detailed account of four ASHAs serving roughly 4000 people is presented. Data transliterated into English were analysed by authors by developing a codebook using grounded theory and thematic organisation of codes.

RESULTS

ASHAs reported facing challenges in ensuring access to health services during and immediately after outbreaks of conflict. They experienced difficulty in arranging transport and breakdown of services at remote health facilities. Their physical safety and security were at risk during episodes of conflict. ASHAs reported hostile attitudes of the communities they served due to the breakdown of social relations, trauma due to displacement, and loss of family members, particularly their husbands.

CONCLUSIONS

Conflict must be recognised as an important context within which community health workers operate, with greater policy focus and research devoted to understanding and addressing the barriers they face as workers and as persons affected by conflict.

Recognizing and mediating bureaucratic barriers: increasing access to care through small private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers, making affordability a challenge. Expanding purchasing arrangements in many countries has helped integrate private providers into government-supported payment schemes and reduced financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in government-supported financing arrangements. The difficulties of this process can be exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion, effectively re-interpreting or re-making policy in practice. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and SHI officials. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a regulatory environment where regulations are weak and impermanent, officials created an accreditation process that was inconsistent and opaque: applying rules unevenly, requesting bribes, and minimizing communication with providers. The support provided by the implementing organizations clarified rules, reduced the power of local bureaucrats to apply regulations at their own discretion, gave providers greater confidence in the system, and helped to standardize the accreditation process. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses, reduce barriers to effective care expansion caused by street-level bureaucrats, and facilitate the adoption of systems which reduce rent-seeking practices that might otherwise delay or derail initiatives to reach universal health coverage.

Physical activity in health care professionals as a means of primary prevention of cardiovascular disease: A STROBE compliant cross-sectional study

The aim of this study was to assess the physical activity level of health care professionals, as well as the differences by sex, age, academic background, and among different health care professions.This is an cross-sectional study.Health care settings in the Valencian Community, Spain.A total of 647 health care professionals.Physical activity was assessed with the European Health Interview Survey-Physical Activity Questionnaire (EHIS-PAQ) that includes the assessment of work-related physical activity, transport-related physical activity, health-enhancing physical activity, muscle-strengthening physical activity, and total physical activity.93.51% of all health care professionals were physically active at work. Transport-related physical activity and health-enhancing physical activity were significantly lower in women (21.62% vs 41.86%, P < .001; and 50.19% vs 68.99%, P < .001, respectively). In addition, compliance with health-enhancing and muscle-strengthening physical activity guidelines were lower in older professionals (42.7% vs 61.84%, P < .001; and 47.57% vs 61.84%, P < .001, respectively). Those with higher education were more compliant with health-enhancing and muscle-strengthening physical activity guidelines (58.55% vs 45.69%, P = .002; and 60.24% vs 48.28%, P = .003, respectively). Moreover, 67.98% of physiotherapists performed health-enhancing physical activity and 67.54% muscle-strengthening physical activity regularly, and significant differences in all outcomes were observed compared to the rest of health care professionals (P < .05). Technicians showed lower work-related and total physical activity than nurses and nursing assistants (74.55% vs 90.37%, P = .002; and 83.64% vs 95.72%, P < .001, respectively). Additionally, nursing assistants showed higher work-related physical activity compared to nurses (97.18% vs 90.37%, P = .008).Most health care professionals showed an appropriate level of physical activity. Men performed more transport-related and health-enhancing physical activity than women. Younger professionals and those with higher education were more compliant with health-enhancing and muscle-strengthening physical activity guidelines. Physiotherapists were more physically active when compared to the rest of health care professionals.

Gender intentional approaches to enhance health social enterprises in Africa: a qualitative study of constraints and strategies

BACKGROUND

Health social enterprises are experimenting with community health worker (CHW) models that allow for various income-generating opportunities to motivate and incentivize CHWs. Although evidence shows that improving gender equality contributes to the achievement of health outcomes, gender-based constraints faced by CHWs working with social enterprises in Africa have not yet been empirically studied. This study is the first of its kind to address this important gap in knowledge.

METHODS

We conducted 36 key informant interviews and 21 focus group discussions between 2016 and 2019 (for a total of 175 individuals: 106 women and 69 men) with four health social enterprises in Uganda and Kenya and other related key stakeholders and domain experts. Interview and focus group transcripts were coded according to gender-based constraints and strategies for enhanced performance as well as key sites for intervention.

RESULTS

We found that CHW programs can be more gender responsive. We introduce the Gender Integration Continuum for Health Social Enterprises as a tool that can help guide gender equality efforts. Data revealed female CHWs face seven unique gender-based constraints (compared to male CHWs): 1) higher time burden and lack of economic empowerment; 2) risks to personal safety; 3) lack of career advancement and leadership opportunities; 4) lack of access to needed equipment, medicines and transport; 5) lack of access to capital; 6) lack of access to social support and networking opportunities; and 7) insufficient financial and non-financial incentives. Data also revealed four key areas of intervention: 1) the health social enterprise; 2) the CHW; 3) the CHW's partner; and 4) the CHW's patients. In each of the four areas, gender responsive strategies were identified to overcome constraints and contribute to improved gender equality and community health outcomes.

CONCLUSIONS

This is the first study of its kind to identify the key gender-based constraints and gender responsive strategies for health social enterprises in Africa using CHWs. Findings can assist organizations working with CHWs in Africa (social enterprises, governments or non-governmental organizations) to develop gender responsive strategies that increase the gender and health outcomes while improving gender equality for CHWs, their families, and their communities.

Informal mhealth at scale in Africa: Opportunities and challenges

The extraordinary global growth of digital connectivity has generated optimism that mobile technologies can help overcome infrastructural barriers to development, with 'mobile health' (mhealth) being a key component of this. However, while 'formal' (top-down) mhealth programmes continue to face challenges of scalability and sustainability, we know relatively little about how health-workers are using their own mobile phones informally in their work. Using data from Ghana, Ethiopia and Malawi, we document the reach, nature and perceived impacts of community health-workers' (CHWs') 'informal mhealth' practices, and ask how equitably these are distributed. We implemented a mixed-methods study, combining surveys of CHWs across the three countries, using multi-stage proportional-to-size sampling (N = 2197 total), with qualitative research (interviews and focus groups with CHWs, clients and higher-level stake-holders). Survey data were weighted to produce nationally- or regionally-representative samples for multivariate analysis; comparative thematic analysis was used for qualitative data. Our findings confirm the limited reach of 'formal' compared with 'informal' mhealth: while only 15% of CHWs surveyed were using formal mhealth applications, over 97% reported regularly using a personal mobile phone for work-related purposes in a range of innovative ways. CHWs and clients expressed unequivocally enthusiastic views about the perceived impacts of this 'informal health' usage. However, they also identified very real practical challenges, financial burdens and other threats to personal wellbeing; these appear to be borne disproportionately by the lowest-paid cadre of health-workers, especially those serving rural areas. Unlike previous small-scale, qualitative studies, our work has shown that informal mhealth is already happening at scale, far outstripping its formal equivalent. Policy-makers need to engage seriously with this emergent health system, and to work closely with those on the ground to address sources of inequity, without undermining existing good practice.

What is nursing work? A meta-narrative review and integrated framework

BACKGROUND

There is ample evidence that modern nurses are under strain and that interventions to support the nursing workforce have not recognised the complexity inherent in nursing work. Creating a modern model of nursing work may assist nurses in developing workable solutions to professional problems. A new model may also foster cohesion among broad and diverse nursing roles.

AIM

The aim of this meta-narrative review was to investigate how researchers, using different methods and theoretical approaches, have contributed to the understanding of nursing work.

METHODS

A meta-narrative review was done to evaluate the trajectory of nursing work research, from 1953 to present. This review progressed through the stages of planning, searching, mapping, appraisal, and synthesis.

FINDINGS

A total of 121 articles were included in this meta-narrative review. These articles revealed five narratives of nursing work, where work is conceptualised as labour. These narratives were physical labour (n = 14), emotional (n = 53), cognitive (n = 24), and organisational (n = 1), and combinations of more than one type of labour (n = 29 articles). The paradigms identified in the meta-narrative were the positivist, interpretive, critical, and evidence-based paradigms. Each article in the review corresponded with a paradigm and a labour narrative, creating a comprehensive model.

CONCLUSIONS

Nursing work can be understood as a model of physical, emotional, cognitive, and organisational labour. These different types of labour may be hidden and taken for granted. Nurses can use this model to articulate what they do and how it supports patient safety. Nurses can also advocate for staffing allocations that consider all types of nursing labour. Tweetable abstract Nursing work is complex and includes physical, emotional, cognitive, and organisational labour. Staffing needs to take all nursing labour into account.

Gender-related influences on adherence to advice and treatment-seeking guidance for infants and young children post-hospital discharge in Bangladesh

BACKGROUND

Post-hospital discharge mortality risk is high among young children in many low and middle-income countries (LMICs). The available literature suggests that child, caregiver and health care provider gender all play important roles in post-discharge adherence to medical advice, treatment-seeking and recovery for ill children in LMICs, including those with undernutrition.

METHODS

A qualitative study was embedded within a larger multi-country multi-disciplinary observational cohort study involving children aged less than 2 years conducted by the Childhood Acute Illness and Nutrition (CHAIN) Network. Primary data were collected from family members of 22 purposively selected cohort children. Family members were interviewed several times in their homes over the 6 months following hospital discharge (total n = 78 visits to homes). These in-depth interviews were complemented by semi-structured individual interviews with 6 community representatives, 11 community health workers and 12 facility-based health workers, and three group discussions with a total of 24 community representatives. Data were analysed using NVivo11 software, using both narrative and thematic approaches.

RESULTS

We identified gender-related influences at health service/system and household/community levels. These influences interplayed to family members' adherence to medical advice and treatment-seeking after hospital discharge, with potentially important implications for children's recovery. Health service/system level influences included: fewer female medical practitioners in healthcare facilities, which influenced mothers' interest and ability to consult them promptly for their child's illnesses; gender-related challenges for community health workers in supporting mothers with counselling and advice; and male caregivers' being largely absent from the paediatric wards where information sessions to support post-discharge care are offered. Gendered household/community level influences included: women's role as primary caretakers for children and available levels of support; male family members having a dominant role in decision-making related to food and treatment-seeking behaviour; and greater reluctance among parents to invest money and time in the treatment of female children, as compared to male children.

CONCLUSIONS

A complex web of gender related influences at health systems/services and household/community levels have important implications for young children's recovery post-discharge. Immediate interventions with potential for positive impact include awareness-raising among all stakeholders - including male family members - on how gender influences child health and recovery, and how to reduce adverse consequences of gender-based discrimination. Specific interventions could include communication interventions in facilities and homes, and changes in routine practices such as who is present in facility interactions. To maximise and sustain the impact of immediate actions and interventions, the structural drivers of women's position in society and gender inequity must also be tackled. This requires interventions to ensure equal equitable opportunities for men and women in all aspects of life, including access to education and income generation activities. Given patriarchal norms locally and globally, men will likely need special targeting and support in achieving these objectives.

Gender Matters: A Gender Analysis of Healthcare Workers’ Experiences during the First COVID-19 Pandemic Peak in England

The coronavirus (COVID-19) arrived in the United Kingdom (UK) in February 2020, placing an unprecedented burden on the National Health Service (NHS). Literature from past epidemics and the COVID-19 pandemic underscores the importance of using a gender lens when considering policy, experiences, and impacts of the disease. Researchers are increasingly examining the experiences of healthcare workers (HCWs), yet there is a dearth of research considering how gender shapes HCWs’ personal experiences. As the majority of HCWs in the UK and worldwide are women, research that investigates gender and focuses on women’s experiences is urgently needed. We conducted an analysis of 41 qualitative interviews with HCWs in the British NHS during the first peak of the COVID-19 pandemic in the Spring of 2020. Our findings demonstrate that gender is significant when understanding the experiences of HCWs during COVID-19 as it illuminates ingrained inequalities and asymmetrical power relations, gendered organizational structures and norms, and individual gendered bodies that interact to shape experiences of healthcare workers. These findings point to important steps to improve gender equality, the wellbeing of healthcare workers, and the overall strength of the NHS.

The vulnerabilities of the Brazilian health workforce during health emergencies: Analysing personal feelings, access to resources and work dynamics during the COVID-19 pandemic

Public health emergencies are a test of resilience for health systems, which depend on health workforces that are well managed and cared for. The COVID‐19 pandemic exposed the weakness of many health systems in preparing their health workforces. The crisis also exacerbated the unequal conditions between different professions, an issue that is still understudied in the workforce literature. This paper analyzes the consequences of the COVID‐19 pandemic for different health professionals, considering the ways in which Brazil's the health system does or does not protect them. We also analyse the role of pre‐existing inequalities between different professions and social groups within the workforce in shaping their different experiences of the pandemic. We present data comparing the perceptions of different health professionals facing the pandemic in Brazil: physicians, nurses, and community health workers. Data were collected in an online survey in Brazil with 1630 health care workers between June 15th and July 1st. Findings suggest that none of the professions felt well prepared to work under emergencies. However, differences relating to professional background were exacerbated during the pandemic, creating unequal conditions for different health workers. These inequalities may pose new challenges for the post‐pandemic scenario.

Why we heal: The evolution of psychological healing and implications for global mental health

Why do humans heal one another? Evolutionary psychology has advanced our understanding of why humans suffer psychological distress and mental illness. However, to date, the evolutionary origins of what drives humans to alleviate the suffering of others has received limited attention. Therefore, we draw upon evolutionary theory to assess why humans psychologically support one another, focusing on the interpersonal regulation of emotions that shapes how humans heal and console one another when in psychosocial distress. To understand why we engage in psychological healing, we review the evolution of cooperation among social species and the roles of emotional contagion, empathy, and self-regulation. We discuss key aspects of human biocultural evolution that have contributed to healing behaviors: symbolic logic including language, complex social networks, and the long period of childhood that necessitates identifying and responding to others in distress. However, both biological and cultural evolution also have led to social context when empathy and consoling are impeded. Ultimately, by understanding the evolutionary processes shaping why humans psychologically do or do not heal one another, we can improve our current approaches in global mental health and uncover new opportunities to improve the treatment of mental illness across cultures and context around the world.

Sex and Gender in Research on Healthcare Workers in Conflict Settings: A Scoping Review

The occupational health literature has established that sex and gender are associated with all dimensions of the workplace. Sex and/or gender (sex/gender) factors play an important role in shaping the experiences, exposures, and health outcomes of male and female healthcare providers working in war and conflict settings. This study aims to (1) assess how sex/gender is considered in the occupational health literature on healthcare workers in conflict settings, and (2) identify the gaps in incorporating sex/gender concepts in this literature. A scoping review was carried out and nine electronic databases were searched using a comprehensive search strategy. Two reviewers screened the titles/abstracts and full-texts of the studies using specific inclusion and exclusion criteria. Key information was extracted from the studies and four themes were identified. Of 7679 identified records, 47 were included for final review. The findings underlined the harsh working conditions of healthcare workers practicing in conflict zones and showed sex/gender similarities and differences in experiences, exposures and health outcomes. This review revealed a dearth of articles with adequate consideration of sex/gender in the study design. Sex/gender-sensitive research in occupational health is necessary to develop effective occupational health and safety policies to protect men and women healthcare workers in conflict settings.

"I Had Nobody to Represent Me": How Perceptions of Diabetes Health-Care Providers' Age, Gender and Ethnicity Impact Shared Decision-Making in Adults With Type 1 and Type 2 Diabetes

OBJECTIVES

Our aim in this study was to investigate how patients' perceptions of their diabetes health-care providers' (HCP) age, gender and ethnicity impact shared decision-making using the Theory of Planned Behaviour.

METHODS

Adult participants receiving diabetes care at community sites, primary care or specialty clinics participated in semistructured, one-on-one interviews conducted from November 2018 to January 2019. Responses were transcribed and qualitatively analyzed for emergent themes using statistical software (NVivo version 9).

RESULTS

We conducted 28 interviews with participants 34 to 81 years of age. The following themes were identified: 1) participants' gestalt of their diabetes HCP was strongly gender dependent 2) there was a hidden preference for Caucasian HCPs, 3) age evoked a less defensive response with regard to shared decision-making and 4) degree of trust in self and in their diabetes HCP directed participants' readiness to be part of the shared decision-making.

CONCLUSIONS

Participants' narrative experiences strongly suggest that they view their diabetes HCPs through a gendered and racialized lens.

'If he sees it with his own eyes, he will understand': how gender informed the content and delivery of a maternal nutrition intervention in Burkina Faso

A growing body of literature urges policymakers, practitioners and scientists to consider gender in the design and evaluation of health interventions. We report findings from formative research to develop and refine an mHealth maternal nutrition intervention in Nouna, Burkina Faso, one of the world's most resource-poor settings. Gender was not an initial research focus, but emerged as highly salient during data collection, and thus guided lines of inquiry as the study progressed. We collected data in two stages, first using focus group discussions (FGD; n = 8) and later using FGDs (n = 2), interviews (n = 30) and observations of intervention delivery (n = 30). Respondents included pregnant women, breastfeeding mothers and Close-to-Community (CTC) providers, who execute preventative and curative tasks at the community level. We applied Morgan et al.'s gender framework to examine intervention content (what a gender-sensitive nutrition programme should entail) and delivery (how a gender-sensitive programme should be administered). Mothers emphasized that although they are often the focus of nutrition interventions, they are not empowered to make nutrition-based decisions that incur costs. They do, however, wield some control over nutrition-related tasks such as farming and cooking. Mothers described how difficult it is to consider only one's own children during meal preparation (which is communal), and all respondents described how nutrition-related requests can spark marital strife. Many respondents agreed that involving men in nutrition interventions is vital, despite men's perceived disinterest. CTC providers and others described how social norms and gender roles underpin perceptions of CTC providers and dictate with whom they can speak within homes. Mothers often prefer female CTC providers, but these health workers require spousal permission to work and need to balance professional and domestic demands. We recommend involving male partners in maternal nutrition interventions and engaging and supporting a broader cadre of female CTC providers in Burkina Faso.

Effectiveness of a health intervention based on WHO food safety manual in Iran

BACKGROUND

Food safety manual was developed by the World Health Organization (WHO) to train professionals to reduce the burden of foodborne diseases as a global strategy. The present pioneering research aimed to explore the effectiveness of an intervention based on the manual of five keys to safer food by WHO in enhancing the knowledge, attitude and behavior of Iranian Female Community Health Volunteers (FCHVs).

METHODS

In the present quasi-experimental research, FCHVs (n = 125) were selected and assigned to two groups, an intervention and a control. A modified version of the questionnaire based on WHO manual was used to measure knowledge, attitude and behavior of the sample. The questionnaire was first completed at the outset of the study (pre-test) and then once again in 2 months of the intervention (post-test). Face and content validity of the questionnaire was tested and confirmed. Cronbach's alpha was used to test the reliability of the questionnaire along with the test-retest method of testing reliability. The data entered SPSS16 for statistical analysis. To this aim, Chi-squared test, dependent and independent samples T-test, ANOVA and ANCOVA were run. Partial population attributable risks were calculated and corresponding 95% confidence intervals (95% CIs) were estimated using a bootstrap method.

RESULTS

The two groups showed no statistically significant difference in the pretest (p > .05). In the post-test, the mean scores for all variables was higher in the intervention group than the control, and this difference between the two research groups was statistically significant (p < .001). When the volunteers were adjusted for age and experience in healthcare centers, the mean scores were significantly higher in the intervention group than the control (p < .001).

CONCLUSION

It was revealed in the present study that the educational intervention based on five keys to food safety manual by WHO managed to improve participants' knowledge, attitude and behavior. Translation of the target guideline in future can be a great help to researchers in prospective research.

TRIAL REGISTRATION

Retrospectively registered: Iranian Registry of Clinical Trials IRCT20160822029485N4, at 2020-03-16.

Health workforce demography: a framework to improve understanding of the health workforce and support achievement of the Sustainable Development Goals

The ambition of universal health coverage entails estimation of the number, type and distribution of health workers required to meet the population need for health services. The demography of the population, including anticipated or estimated changes, is a factor in determining the 'universal' needs for health and well-being. Demography is concerned with the size, breakdown, age and gender structure and dynamics of a population. The same science, and its robust methodologies, is equally applicable to the demography of the health workforce itself. For example, a large percentage of the workforce close to retirement will impact availability, a geographically mobile workforce has implications for health coverage, and gender distribution in occupations may have implications for workforce acceptability and equity of opportunity. In a world with an overall shortage of health workers, and the expectation of increasing need as a result of both population growth in the global south and population ageing in the global north, studying and understanding demographic characteristics of the workforce can help with future planning. This paper discusses the dimensions of health worker demography and considers how demographic tools and techniques can be applied to the analysis of the health labour market. A conceptual framework is introduced as a step towards the application of demographic principles and techniques to health workforce analysis and planning exercises as countries work towards universal health coverage, the reduction of inequities and national development targets. Some illustrative data from Nepal and Finland are shown to illustrate the potential of this framework as a simple and effective contribution to health workforce planning.

'The phone is my boss and my helper' - A gender analysis of an mHealth intervention with Health Extension Workers in Southern Ethiopia

Background

There is considerable optimism in mHealth’s potential to overcome health system deficiencies, yet gender inequalities can weaken attempts to scale-up mHealth initiatives. We report on the gendered experiences of an mHealth intervention, in Southern Ethiopia, realised by the all-female cadre of Health Extension Workers (HEWs).

Methodology

Following the introduction of the mHealth intervention, in-depth interviews (n = 19) and focus group discussions (n = 8) with HEWs, supervisors and community leaders were undertaken to understand whether technology acted as an empowering tool for HEWs. Data was analysed iteratively using thematic analysis informed by a socio-ecological model, then assessed against the World Health Organisation’s gender responsive assessment scale.

Results

HEWs reported experiencing: improved status after the intervention; respect from community members and were smartphone gatekeepers in their households. HEWs working alone at health posts felt smartphones provided additional support. Conversely, smartphones introduced new power dynamics between HEWs, impacting the distribution of labour. There were also negative cost implications for the HEWs, which warrant further exploration.

Conclusion

MHealth has the potential to improve community health service delivery and the experiences of HEWs who deliver it. The introduction of this technology requires exploration to ensure that new gender and power relations transform, rather than disadvantage, women.

Keywords

communities, e-health, gender

The influence of gender on immunisation: using an ecological framework to examine intersecting inequities and pathways to change

There is still a substantial knowledge gap on how gender mediates child health in general, and child immunisation outcomes in particular. Similarly, implementation of interventions to mitigate gender inequities that hinder children from being vaccinated requires additional perspectives and research. We adopt an intersectional approach to gender and delve into the social ecology of implementation, to show how gender inequities and their connection with immunisation are grounded in the interplay between individual, household, community and system factors. We show how an ecological model can be used as an overarching framework to support more precise identification of the mechanisms causing gender inequity and their structural complexity, to identify suitable change agents and interventions that target the underlying causes of marginalisation, and to ensure outcomes are relevant within specific population groups.

Gender and health social enterprises in Africa: a research agenda

Background

Health social enterprises in Africa working with community health workers (CHWs) are growing rapidly but understudied. In particular, gender equality issues related to their work has important public health and equity implications.

Methods

Particularly suited for generating timely findings from reviews at the intersection of overlapping disciplines, we utilized the rapid evidence assessment (REA) methodology to identify key unanswered research questions at the intersection of the fields of gender equality, social enterprises and community health workers. The REA used a series of structured Google Scholar searches, expert interviews and bibliography reviews to identify 57 articles in the academic and grey literatures that met the study inclusion criteria. Articles were thematically coded to identify answers to “What are the most important research questions about the influence of gender on CHWs working with health social enterprises in Africa?”

Results

The analysis identified six key unanswered research questions relating to 1) equitable systems and structures; 2) training; 3) leadership development and career enhancement; 4) payment and incentives; 5) partner, household and community support; and 6) performance.

Conclusion

This is the first study of its kind to identify the key unanswered research questions relevant to gender equality in health social enterprises in Africa using community health workers. As such, it sets out a research agenda for this newly emerging but rapidly developing area of research and practice with important public health implications.

The intersection of sex and gender in the treatment of influenza

Males/men and females/women differ in the outcome of influenza A virus (IAV) infections, vaccination, and antiviral treatments. Both sex (i.e. biological factors) and gender (i.e. sociocultural factors) can impact exposure and severity of IAV infections as well as responses and outcomes of treatments for IAV. Greater consideration of the combined effects of sex and gender in epidemiological, clinical, and animal studies of influenza pathogenesis is needed.

How are gender inequalities facing India's one million ASHAs being addressed? Policy origins and adaptations for the world's largest all-female community health worker programme

BACKGROUND

India's accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Launched in 2005, there is now an ASHA in almost every village and across many urban centres who support health system linkages and provide basic health education and care. This paper examines how the programme is seeking to address gender inequalities facing ASHAs, from the programme's policy origins to recent adaptations.

METHODS

We reviewed all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. We also drew from the embedded knowledge of this paper's government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens.

RESULTS

Given that the initial impetus for the ASHA programme was to address reproductive and child health issues, policymakers viewed volunteer female health workers embedded in communities as best positioned to engage with beneficiaries. From these instrumentalist origins, where the programme was designed to meet health system demands, policy evolved to consider how the health system could better support ASHAs. Policy reforms included an increase in the number and regularity of incentivized tasks, social security measures, and government scholarships for higher education. Residential trainings were initiated to build empowering knowledge and facilitate ASHA solidarity. ASHAs were designated as secretaries of their village health committees, encouraging them to move beyond an all-female sphere and increasing their role in accountability initiatives. Measures to address gender based violence were also recently recommended. Despite these well-intended reforms and the positive gains realized, ongoing tensions and challenges related to their gendered social and employment status remain, requiring continued policy attention and adaptation.

CONCLUSIONS

Gender trade offs and complexities are inherent to sustaining CHW programmes at scale within challenging contexts of patriarchal norms, health system hierarchies, federal governance structures, and evolving aspirations, capacities, and demands from female CHWs. Although still grappling with significant gender inequalities, policy adaptations have increased ASHAs' access to income, knowledge, career progression, community leadership, and safety. Nonetheless, these transformative gains do not mark linear progress, but rather continued adaptations.

Delivery of Community-Based Care Through Inter-professional Teams in Brazil's Unified Health System (UHS): Comparing Perceptions Across Community Health Agents (CHAs), Nurses and Physicians

Given the shortage of medical providers and the need for medical decisions to be responsive to community needs, including lay health providers in health teams has been recommended as essential for the successful management of global health care systems. Brazil's Unified Health System (UHS) is a model for delivering community-based care through Family Health Strategy (FHS) interdisciplinary teams comprised of medical and lay health providers-Community Health Agents (CHAs), nurses, and physicians. This study aims to understand how medical and lay health providers' perceptions and attitudes could impact the delivery of community-based care. The study compares perceptions and attitudes of 168 CHAs, 62 nurses, and 32 physicians across their job context, professional capacities, professional skills, and work environment. Descriptive and bivariate analysis were performed. CHAs reported being the most efficacious amongst the providers. Physicians reported incorporating consumer-input to a lesser degree than nurses and CHAs. CHAs reported using a lesser variety of skills than physicians. A significant proportion of physicians compared to CHAs and nurses reported that they had decision-making autonomy. Providers did not report differences that lack of resources and poor work conditions interfered with their ability to meet consumer needs. This study offers technocratic perspectives of medical and lay health providers who as an inter-professional team provide community-based primary health care. Implications of the study include proposing training priorities and identifying strategies to integrate lay health providers into medical teams for Brazil's Unified Health System and other health systems that aim to deliver community-based care through inter-professional health teams.

Reflecting strategic and conforming gendered experiences of community health workers using photovoice in rural Wakiso district, Uganda

BACKGROUND

Community health workers (CHWs) are an important human resource in Uganda as they are the first contact of the population with the health system. Understanding gendered roles of CHWs is important in establishing how they influence their performance and relationships in communities. This paper explores the differential roles of male and female CHWs in rural Wakiso district, Uganda, using photovoice, an innovative community-based participatory research approach.

METHODS

We trained ten CHWs (five males and five females) on key concepts about gender and photovoice. The CHWs took photographs for 5 months on their gender-related roles which were discussed in monthly meetings. The discussions from the meetings were recorded, transcribed, and translated to English, and emerging data were analysed using content analysis in Atlas ti version 6.0.15.

RESULTS

Although responsibilities were the same for both male and female CHWs, they reported that in practice, CHWs were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male CHWs and females turning to female CHWs. Due to their privileged ownership and access to motorcycles, male CHWs were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labour in communities, male CHWs were also observed to be more involved in manual work such as cleaning wells. The gendered division of labour also reinforced female caregiving roles related to child care, and also made female CHWs more available to address local problems.

CONCLUSIONS

CHWs reflected both strategic and conformist gendered implications of their community work. The differing roles and perspectives about the nature of male and female CHWs while performing their roles should be considered while designing and implementing CHW programmes, without further retrenching gender inequalities or norms.

Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health

Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.

Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health

Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.

The gendered health workforce: mixed methods analysis from four fragile and post-conflict contexts

It is well known that the health workforce composition is influenced by gender relations. However, little research has been done which examines the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). We present mixed method research on HRH in four fragile and post-conflict contexts (Sierra Leone, Zimbabwe, northern Uganda and Cambodia) with different histories to understand how gender influences the health workforce. We apply a gender analysis framework to explore access to resources, occupations, values, decision-making and power. We draw largely on life histories with male and female health workers to explore their lived experiences, but complement the analysis with evidence from surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. Our findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level, affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences here shaped by gender, poverty and household structure. Most HRH regulatory frameworks did not sufficiently address gender concerns. Unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.

Gender inequities in curative and preventive health care use among infants in Bihar, India

Background

India has the highest rate of excess female infant deaths in the world. Studies with decade-old data suggest gender inequities in infant health care seeking, but little new large-scale research has examined this issue. We assessed differences in health care utilization by sex of the child, using 2014 data for Bihar, India.

Methods

This was a cross-sectional analysis of statewide representative survey data collected for a non-blinded maternal and child health evaluation study. Participants included mothers of living singleton infants (n = 11 570). Sex was the main exposure. Outcomes included neonatal illness, care seeking for neonatal illness, hospitalization, facility-based postnatal visits, immunizations, and postnatal home visits by frontline workers. Analyses were conducted via multiple logistic regression with survey weights.

Findings

The estimated infant sex ratio was 863 females per 1000 males. Females had lower rates of reported neonatal illness (odds ratio (OR) = 0.7, 95% confidence interval (CI) = 0.6–0.9) and hospitalization during infancy (OR = 0.4, 95% CI = 0.3–0.6). Girl neonates had a significantly lower odds of receiving care if ill (80.6% vs 89.1%; OR = 0.5; 95% CI = 0.3–0.8) and lower odds of having a postnatal checkup visit within one month of birth (5.4% vs 7.3%; OR = 0.7, 95% CI = 0.6–0.9). The gender inequity in care seeking was more profound at lower wealth and higher numbers of siblings. Gender differences in immunization and frontline worker visits were not seen.

Interpretation

Girls in Bihar have lower odds than boys of receiving facility–based curative and preventive care, and this inequity may partially explain the persistent sex ratio imbalance and excess female mortality. Frontline worker home visits may offer a means of helping better support care for girls.

Pushing the boundaries of research on human resources for health: fresh approaches to understanding health worker motivation

A country's health workforce plays a vital role not only in serving the health needs of the population but also in supporting economic prosperity. Moreover, a well-funded and well-supported health workforce is vital to achieving universal health coverage and Sustainable Development Goal 3 to ensure healthy lives and promote well-being for all at all ages. This perspective article highlights the potential of underutilized health policy and systems research (HPSR) approaches for developing more effective human resources for health policy. The example of health worker motivation is used to showcase four types of HPSR (exploratory, influence, explanatory and emancipatory) that move beyond describing the extent of a problem. Most of the current literature aiming to understand determinants and dynamics of motivation is descriptive in nature. While this is an important basis for all research pursuits, it often gives little information about mechanisms to improve motivation and strategies for intervention. Motivation is an essential determinant of health worker performance, particularly for those working in difficult conditions, such as those facing many health workers in low- and middle-income countries. Motivation mediates health workforce performance in multiple ways: internally governing health worker behaviour; informing decisions on becoming a health worker; workplace location and ability to perform; and influencing willingness to engage politically. The four fresh research approaches described can help policy-makers better understand why health workers behave the way they do, how interventions can improve performance, the mechanisms that lead to change, and strategies for empowering health workers to be agents of change themselves.

Minding the gaps: health financing, universal health coverage and gender

In a webinar in 2015 on health financing and gender, the question was raised why we need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage (UHC) will automatically be equitable and gender balanced. This article provides a reflection on this question from a panel of health financing and gender experts.We trace the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. We find that unless explicit attention is paid to gender and its intersectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations (e.g. poor women, unemployed men, female-headed households), movement towards UHC can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to UHC and the needs of less powerful groups, which can include women and children, are not necessarily given priority.We identify the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of UHC decisions, political economy as well as technical research should be prioritized.We conclude that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children. This constitutes the 'progressive universalism' advocated for by the 2013 Lancet Commission on Investing in Health.

The contribution of female community health volunteers (FCHVs) to maternity care in Nepal: a qualitative study

Background

In resource-poor settings, the provision of basic maternity care within health centres is often a challenge. Despite the difficulties, Nepal reduced its maternal mortality ratio by 80% from 850 to an estimated 170 per 100,000 live births between 1991 and 2011 to achieve Millennium Development Goal Five. One group that has been credited for this is community health workers, known as Female Community Health Volunteers (FCHVs), who form an integral part of the government healthcare system. This qualitative study explores the role of FCHVs in maternal healthcare provision in two regions: the Hill and Terai.

Methods

Between May 2014 and September 2014, 20 FCHVs, 11 health workers and 26 service users were purposefully selected and interviewed using semi-structured topic guides. In addition, four focus group discussions were held with 19 FCHVs. Data were analysed using thematic analysis.

Results

All study participants acknowledged the contribution of FCHVs in maternity care. All FCHVs reported that they shared key health messages through regularly held mothers’ group meetings and referred women for health checks. The main difference between the two study regions was the support available to FCHVs from the local health centres. With regular training and access to medical supplies, FCHVs in the hill villages reported activities such as assisting with childbirth, distributing medicines and administering pregnancy tests. They also reported use of innovative approaches to educate mothers. Such activities were not reported in Terai. In both regions, a lack of monetary incentives was reported as a major challenge for already overburdened volunteers followed by a lack of education for FCHVs.

Conclusions

Our findings suggest that the role of FCHVs varies according to the context in which they work. FCHVs, supported by government health centres with emphasis on the use of local approaches, have the potential to deliver basic maternity care and promote health-seeking behaviour so that serious delays in receiving healthcare can be minimised. However, FCHVs need to be reimbursed and provided with educational training to ensure that they can work effectively. The study underlines the relevance of community health workers in resource-poor settings.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2567-7) contains supplementary material, which is available to authorized users.

Per Diems in Polio Eradication: Perspectives From Community Health Workers and Officials

Nearly all global health initiatives give per diems to community health workers (CHWs) in poor countries for short-term work on disease-specific programs. We interviewed CHWs, supervisors, and high-level officials (n = 95) in 6 study sites across sub-Saharan Africa and South Asia in early 2012 about the per diems given to them by the Global Polio Eradication Initiative. These per diems for CHWs ranged from $1.50 to $2.40 per day. International officials defended per diems for CHWs with an array of arguments, primarily that they were necessary to defray the expenses that workers incurred during campaigns. But high-level ministry of health officials in many countries were concerned that even small per diems were unsustainable. By contrast, CHWs saw per diems as a wage; the very small size of this wage led many to describe per diems as unjust. Per diem polio work existed in the larger context of limited and mostly exploitative options for female labor. Taking the perspectives of CHWs seriously would shift the international conversation about per diems toward questions of labor rights and justice in global health pay structures.

Relaunch of the official community health worker programme in Mozambique: is there a sustainable basis for iCCM policy?

Background: In Mozambique, integrated community case management (iCCM) of diarrhoea, malaria and pneumonia is embedded in the national community health worker (CHW) programme, mainstreaming it into government policy and service delivery. Since its inception in 1978, the CHW programme has functioned unevenly, was suspended in 1989, but relaunched in 2010. To assess the long-term success of iCCM in Mozambique, this article addresses whether the current CHW programme exhibits characteristics that facilitate or impede its sustainability.

Methodology: We undertook a qualitative case study based on document review (n = 54) and key informant interviews (n = 21) with respondents from the Ministry of Health (MOH), multilateral and bilateral agencies and non-governmental organizations (NGOs) in Maputo in 2012. Interviews were mostly undertaken in Portuguese and all were coded using NVivo. A sustainability framework guided thematic analysis according to nine domains: strategic planning, organizational capacity, programme adaptation, programme monitoring and evaluation, communications, funding stability, political support, partnerships and public health impact.

Results: Government commitment was high, with the MOH leading a consultative process in Maputo and facilitating successful technical coordination. The MOH made strategic decisions to pay CHWs, authorize their prescribing abilities, foster guidance development, support operational planning and incorporate previously excluded ‘old’ CHWs. Nonetheless, policy negotiations excluded certain key actors and uncertainty remains about CHW integration into the civil service and their long-term retention. In addition, reliance on NGOs and donor funding has led to geographic distortions in scaling up, alongside challenges in harmonization. Finally, dependence on external funding, when both external and government funding are declining, may hamper sustainability.

Conclusions: Our analysis represents a nuanced assessment of the various domains that influence CHW programme sustainability, highlighting strategic areas such as CHW payment and programme financing. These organizational and contextual determinants of sustainability are central to CHW programme strengthening and iCCM policy support.

Why do entrepreneurial mHealth ventures in the developing world fail to scale?

Telemedicine is an increasingly common approach to improve healthcare access in developing countries with fledgling healthcare systems. Despite the strong financial, logistical and clinical support from non-governmental organisations (NGOs), government ministries and private actors alike, the majority of telemedicine projects do not survive beyond the initial pilot phase and achieve their full potential. Based on a review of 35 entrepreneurial telemedicine and mHealth ventures, and 17 reports that analyse their operations and challenges, this article provides a narrative review of recurring failure modes, i.e. factors that lead to failure of such venture pilots. Real-world examples of successful and failed ventures are examined for key take-away messages and practical strategies for creating commercial viable telemedicine operations. A better understanding of these failure modes can inform the design of sustainable and scalable telemedicine systems that effectively address the growing healthcare disparities in developing countries.